The case of a 42 year old male foreman who died after falling 17 feet from a steel beam and becoming impaled on a 0.5 inch diameter cement reinforcement rod was examined. The victim was employed as a foreman by a steel erection company. The company had no written safety program. Employees received on the job training, and work safety procedures were discussed during tailgate meetings at the site. Five workers, including the victim, were engaged in construction of a steel I-beam framework of a mini mall. The victim and a coworker were sitting on opposite ends of a beam while it was lifted into position approximately 17 feet above the ground. Neither man was using fall protection devices. When the beam was in position, the coworker grasped a column and prepared to make the connection. As he reached behind himself to grab his wrench from his belt, the wire rope choker supporting the beam slid toward the victim. The coworker fell from the beam into the 3 foot deep ditch containing the concrete footing. The victim slid toward the connecting collar, causing the beam to stand straight up. The victim then fell from the beam, landing in the ditch on his right side, impaled on the 0.5 inch reinforcement rod. The rod penetrated 8 inches into the victim's body, piercing his heart. Cause of death was listed as exsanguination due to penetrating injury. It is recommended that employers ensure that employees do not ride loads that are being lifted or otherwise moved by a crane. Employers should also ensure that recognized hazards are guarded or otherwise controlled before any work is performed.